Contrary to any claims to the contrary, the Affordable Care Act did not fail. It succeeded brilliantly in two ways. The first and most practical way is that under the auspices of the ACA a lot of people received insurance and substantial subsidies who otherwise would not have done so.
The other and probably more lasting way in which the ACA succeeded was that it moved the Overton Window. Of the two guiding principles of the ACA, it is pretty clear that guaranteed issue has become an enduring part of the conversation.
If community rating does as well, it will constitute a rejection of the insurance model as applied to paying for healthcare. I have no idea what will replace it. Nationalizing it is no solution, as I mentioned earlier today.
The strategies employed by other OECD countries probably won’t be much of a guide. Our problems are unique. For one thing we’re the only country in the world that shares a 1,500 mile land border with a country where the median income is a quarter what it is here.
Could have put this in your prior post also, but I continue to think (I think you don’t) that this was just the first step all along. You wouldn’t get buy in trying to do everything at once. If this really has moved the window, it makes it easier to achieve something closer to universal coverage. With that, you can then seriously tackle costs.
Also, I would quibble a tiny bit with the border thing. While technically true, the more prosperous EU countries are adjacent to EU countries and non-EU countries that are much worse off. Recent events have shown it is not difficult for refugees to come from Turkey and Syria.
Steve
I guess it depends on your operative definition of first step. If by it you mean starting out with something, backtracking, tearing it down completely and starting over, I agree it’s a first step. Can you give an example of our having done that in the past?
I can think of social programs which, having been adopted sometimes for extended periods, were discarded (AFDC). I can think of social programs that were enacted with bipartisan support and elaborated on and modified over a period of decades (SSRI, Medicaid, etc.) I can’t think of any that fit the ACA model you’re suggesting.
It’s something I complained about six or seven years ago. No groundwork was laid for future negotiations. No alliances formed, relationships established. It was pretty darned partisan to be the first of many steps, each building on the previous.
As to the response of European countries to mass immigration from MENA—it’s relatively recent so we’ll need to wait and see. You can’t point to their response as a model for what we might do, at least not yet. What I see so far is substantial chafing rather than something we might want to emulate.
@steve, on “first step” I wrote my criticism in the next thread before reading your comment. But politically, I think you are flat-out wrong. If this was just a first step, it needed bipartisan support, even if it meant taking a half-step.
I think the lack of genuine bipartisan collaboration, followed by more diverse support was a foundational flaw in the ACA. Essentially, the negative blow back has equalled the aggressive and forced push to get it unilaterally passed.
Dave, I think your comment could be extended to basically the whole of domestic policy for the past 8 years.
We can complain the Republicans never offered any alternatives to be negotiated over, but the ACA didn’t even get all Democrats (of that time) on board. 34 house Democrats and 3 senate Democrats (on the reconciliation bill) voted against. The Democrats are more unified on the ACA now, but they gave a chunk of the party to the Republicans.
The only time I recall where Obama really tried to compromise was the ill-fated grand bargain of 2011. After that debacle and President Obama won reelection, I feel President Obama wrongly concluded that negotiating was a fools errand and voters supported he go it alone. I think a better conclusion was that Obama and Republicans shared responsibility in the botched negotiations, that Obama should work harder on negotiations, and his narrower reelection victory was not vindication, but a caution.
Its also regretful how Obama resisted ANY changes to the law at all, even if it could broaden its base of support. If Obama had stated he would sign any legislation modifying ACA that could get a plurality of congressional democrats as well as republicans, Republicans would have had to make a good faith effort to find compromise, and (a) either a compromise would have been found, and the law would gain the bipartisan support it needs, or (b) Democrats would have a real messaging point. As it is, the refusal to accept any modifications has left Democrats out in the cold as Republicans perform a major overhaul on the law.
Finally, I have always wondered if the US is going at health reform the wrong way. The Canadian system Democrats admire is provincially run, the Canadian government role is basically to hand cash over to the provinces and pronounce the vaguest of standards. The provinces have the advantage of better tailoring their health system to local needs. Its crazy to me that with the difficulty Canadian provinces have in managing health care for 1 – 10 million people, people think the US government can manage health care for 300 million people. If Democrats want to pursue more health care reform, working at the State level may lead to better results.
I agree with 99% of what you wrote in your comment, CuriousOnlooker. However, it’s a bit hard for me to make out what the contours of a compromise would be. The Ryan plan, the best signal we have for what Republicans might support, is transparently a plan for edging the federal government out of healthcare altogether, presumably in favor of catastrophic health insurance. The Democrats for their part want to expand coverage and maximize the centralization of control.
The problem you refer to as “unique” is only a problem because people like Steve Bannon haven’t been at the helm for a long while.
Like before the Ted Kennedy’s destructive legislative thrusts on immigration made it a probably lethal problem among a few.
Well, I didn’t support Obamacare, it didn’t really take health care policy where I wanted it.
A piece that could be tradable with the republicans is some of the moral objections — this is going to get heckles, they are important symbols but they don’t effect health care that much. The republicans might offer a lot to get those changes.
The compromise I would propose is for the democrats let republicans take the heat for doing whatever they are going to do, in return for whatever authorities and powers are needed for a State to implement universal coverage.
Canada and the US are different, we’ve talked about that. But the Canadian example (where a province implemented universal coverage first, and then other provinces copied, and finally the federal government normalized what was common) is useful as it shows a policy path that is incremental, respects the federal nature of the US, and is compatible with the culture of at least a significant part of the US. And a focus on the states will help the Democrats strengthen their reach.
Without perseverating on it, here’s the problem: Vermont, the most likely candidate, has already whiffed.
Strike two: Hawaii’s employer mandate has been in place for more than 30 years. No other state has been moved to emulate Hawaii.
The single most significant factor in the number of uninsured in a state seems to be related to the composition of its immigrant population. Until that can be discussed openly without fear of being attacked for racism, it’s darned hard to come to terms with our problems.
I was just getting ready to mention Vermont, but there are a couple of counter-intuitive opportunities that may be arising. Vermont ultimately whiffed because it didn’t want to to raise taxes, contra whatever path-not-taken Kevin Drum thinks existed. The Republicans seem to think federal taxes still need to be cut significantly, and if they are, it would make state tax increases more palatable. Second, while I am dubious of the politics around Ryan Medicare reform, access to Medicare dollars was one of the other things that would have helped Vermont’s single-payer plan.
That said, Vermont’s size and demographics seem to make this feasible, but maybe not imitable.
Dave- Medicare. First, they got all of the old people insured. Then they saw that the rate of increase in spending was too fast in the 70s and early 80s. They changed payments and it slowed down.
PD, jan- Was not going to happen. Any Republican who participated would face a primary challenge. Look what happened to Bennett. Hell, Republicans were asked to participate and it slowed things down enough the bill almost didn’t pass. Best version of events at link.
http://www.theatlantic.com/politics/archive/2015/07/the-real-story-of-obamacares-birth/397742/
Curious- The states have largely been uninterested in health care reform. There wasnt much stopping them from going ahead with it over the last 30 years. Fine with me if the states want to take it on, but history shows they aren’t interested. Also, I rarely see health policy people on the left point to Canada as a preferred model. Germany, France, Switzerland, Singapore, Taiwan, Australia or even Japan get more mention. Finally, what changes to the ACA did the GOP suggest?
Steve
@steve, your comparison to Bennett isn’t persuasive. Snowe lives in a blue state and voted the Senate version of the ACA out of committee. She voted for the stimulus bill, Dodd-Frank, Obama’s SCOTUS justices (that made it to the floor), she voted against partial-birth abortion bans, and voted to repeal Don’t Ask Don’t Tell.
If she was afraid of conservatives, she didn’t show it very well. While Obama courted Snowe, Harry Reid closed the process to her. I don’t know the specifics of what she wanted. She appears to have wanted a trigger that allowed for a federal public option to become available in the event that private insurance was unaffordable. She complained that nobody could explain to her what made this law “affordable.” She was ignored by the sponsors. It looks like the Democrats sought Lieberman’s vote more than Snowe’s because Lieberman wanted the public option killed.
It is an absurd misreading of history to pretend that compromise was possible with the GOP. Utter nonsense. Go back and read the contemporaneous statements by major GOP voices. This is one of those lies that is being absorbed into the national bloodstream as truth. But it remains untrue.
PD- Bennett demonstrates what happens, after the fact of course, to those who deviate. In the case of Snowe, who could be more vulnerable that a moderate Senator from a barely blue state? Yes, she was useful to the GOP when they needed to vote for something the public supported. In the cases you cite there was public support for what the Dems were passing, so McConnell could afford to let her vote the way she did. I know that you are well enough read to know how that game is played. However, the ACA was going to be Obama’s signature bill. They unified against that. They delayed the passage of the ACA for months while the Group of Six met.
The Dems took large sections of the ACA directly from prior GOP legislation. They actively solicited input from GOP senators. What more could they really have done? Finally, what could any individual GOP senator have gotten out of it that would not have jeopardized their future in the party.
Again, in case Curious reads this, what specific changes did the GOP really offer. They passed a zillion repeal efforts. I really don’t remember that many change efforts, but Obama did sign ones that passed Congress that weren’t part of a repeal effort or defunding effort. Link below to one and in the body of the article is the other one I can remember.
http://www.huffingtonpost.com/entry/congress-passed-bill-to-change-obamacare_us_5612af43e4b076812702b75f
Steve
@steve: Obama was open to the alterations Snowe suggested; Harry Reid did not want GOP involvement. Reid initially promised Snowe an open amendment promise then withdrew it. Snowe has written a book on this and done interviews, and has never intimated that McConnell pressured her. Snowe called him to let him know that she was going to vote the ACA bill out of committee and he said he appreciated the heads-up, but was obviously disappointed. That was it. Most of her complaints are about Reid, and the reason that there was no Republican support for the bill was Reid.
“They actively solicited input from GOP senators.” Snowe says that her suggestions and questions to the bill sponsors were ignored. Again, she has good things to say about Obama reaching out to her, but he wouldn’t interfere with Senate leadership.
The GOP leadership had made it quite clear that they would oppose anything Obama or Harry Reid came out with. An open amendments process would have just opened the door to endless Republican obstruction.
The notion that the GOP had any interest in reforming health care is laughable. Look no further than the news that Paul Ryan plans to kill it without even offering a replacement. The GOP is killing Obamacare out of pure spite, the same reason they decided to oppose it and every other Obama effort: they were not about to let a black president succeed.